Thursday, July 23, 2015

Want to train a better generation of physicians? See to it that they develop the sensibility of artists.

That's the argument Dr. Caroline Wellbery and Dr. Rebecca McAteer of the Georgetown University School of Medicine make in an essay just published in the journal Academic Medicine. Utilizing insights from research (as well as their own experience), they propose a curriculum for an eight-week "arts observation seminar" that could provide invaluable new perspectives to aspiring doctors.

They argue that such a program, which would encompass poetry, photography, and descriptive writing, could aid young physicians in three crucial ways: Encouraging them to "see with an open mind," rather than reflexively linking a set of symptoms with a textbook diagnosis; honing their ability to describe their observations with nuance and precision; and teaching them how to effectively articulate their ideas to patients and colleagues.

"The literary and visual arts," they write, "have long-standing and venerable roles in fortifying the lessons of clinical empathy, communication skills, critical thinking, and attention"—crucial qualities that can easily get overlooked in an era of assembly line office visits, where a doctor's attention is often more focused on lab-test data than actual communion with the patient.

SPINY GRASS AND SCRAGGLY PINEScreep amid the arts-and-crafts buildings of the Asilomar Conference Grounds, 100 acres of dune where California's Monterey Peninsula hammerheads into the Pacific. It's a rugged landscape, designed to inspire people to contemplate their evolving place on Earth. So it was natural that 140 scientists gathered here in 1975 for an unprecedented conference.

They were worried about what people called "recombinant DNA," the manipulation of the source code of life. It had been just 22 years since James Watson, Francis Crick, and Rosalind Franklin described what DNA was—deoxyribonucleic acid, four different structures called bases stuck to a backbone of sugar and phosphate, in sequences thousands of bases long. DNA is what genes are made of, and genes are the basis of heredity.

Preeminent genetic researchers like David Baltimore, then at MIT, went to Asilomar to grapple with the implications of being able to decrypt and reorder genes. It was a God-like power—to plug genes from one living thing into another. Used wisely, it had the potential to save millions of lives. But the scientists also knew their creations might slip out of their control. They wanted to consider what ought to be off-limits.

The film "Thank You for Playing," which premièred at this year's Tribeca Film Festival, follows a young father who is making a video game about his terminally ill child. Joel Green was diagnosed with terminal cancer in 2010, at the age of one. By the time the film's directors, David Osit and Malika Zouhali-Worrall, first met him, in early 2013, Joel's young body had been subject to more than three years of surgery and chemotherapy. The tumors had left him partially deaf and blind. At one point, he had to relearn how to walk. Other families might document and express a similar experience through photographs, home videos, written diaries, or poems. But Joel's father, Ryan Green, is a video-game developer, and he decided to bring narrative order to the devastating chaos of his son's illness using the medium he knows best.

Video games often provide a form of escape, both for their players and, at times, for their designers. But for Green "That Dragon, Cancer," as his game is called, served an opposite purpose—as a way to invite others to share his real-life experience. An early demo of the game, released a few months after Green and his friend and development partner Josh Larson began work on it, in November of 2012, held nothing back in its depiction of the family's plight. In one vignette, you sit, as Green once did, in a hospital room, which is quiet apart from the hum of inscrutable machines and Joel's haunting screams. The game's style is impressionistic (there are no features, for instance, on the face of Joel's avatar), but the effect of a baby's cries is undiminished in a virtual world. In video games, we have grown used to confronting the problems their designers present and solving them with relative ease, often via a gun's sights, a shunted block, or a virtual key. In this scene, the problem is inescapable, and the sense of anguish when your attempts to calm Joel fail is grimly authentic. As the young boy bangs his head against the rails of his narrow cot, you hunt in vain for a button that might make it all stop.

It was 8 o'clock on a weeknight and Brooklyn resident Sarah Sheehan was reeling from a painful earache.

She wouldn't be able to see her doctor until the next morning, and that would require a 45-minute subway ride uptown. That's when Sheehan, co-founder of an education technology business, remembered receiving a promotional code for a new company called Pager, an Uber-like service that sends doctors to patients' homes.

Pager and similar companies like Heal and Medicast aim to streamline medical care -- cutting out waiting rooms, receptionists and trips to the doctor's office.

"It's a completely different experience when you're sick and able to stay in your pajamas," says Sheehan. "Someone comes to your home, they're kind to you, they answer all your questions and give you all the time you need."

As complaints grow about exorbitant drug prices, pharmaceutical companies are coming under pressure to disclose the development costs and profits of those medicines and the rationale for charging what they do.

So-called pharmaceutical cost transparency bills have been introduced in at least six state legislatures in the last year, aiming to make drug companies justify their prices, which are often attributed to high research and development costs.

"If a prescription drug demands an outrageous price tag, the public, insurers and federal, state and local governments should have access to the information that supposedly justifies the cost," says the preamble of a bill introduced in the New York State Senate in May.

Wednesday, July 22, 2015

One summer day 14 years ago, when I was a new cardiology fellow, my colleagues and I were discussing the case of an elderly man with worsening chest pains who had been transferred to our hospital to have coronary bypass surgery. We studied the information in his file: On an angiogram, his coronary arteries looked like sausage links, sectioned off by tight blockages. He had diabetes, high blood pressure and poor kidney function, and in the past he had suffered a heart attack and a stroke. Could the surgeons safely operate?

In most cases, surgeons have to actually see a patient to determine whether the benefits of surgery outweigh the risks. But in this case, a senior surgeon, on the basis of the file alone, said the patient was too "high risk." The reason he gave was that state agencies monitoring surgical outcomes would penalize him for a bad result. He was referring to surgical "report cards," a quality-improvement program that began in New York State in the early 1990s and has since spread to many other states.

Sunday, July 19, 2015

AMERICAN psychiatry is facing a quandary: Despite a vast investment in basic neuroscience research and its rich intellectual promise, we have little to show for it on the treatment front.

With few exceptions, every major class of current psychotropic drugs — antidepressants, antipsychotics, anti-anxiety medications — basically targets the same receptors and neurotransmitters in the brain as did their precursors, which were developed in the 1950s and 1960s.